Occupational (In)visibility: The emerging role of the Remote Education Tutor as an educational conduit.

Remote Education Tutors (RETs) are central to the delivery of distance schooling in Australia and are accountable for the face-to face supervision and educational support of students. They act as the government mandated adult supervisors of Australian primary and secondary school students enrolled in distance education, including geographically isolated learners. This paper draws on statistical data from a national survey (N = 575) that was designed to map the perceptions of Australian RETs. These data confirmed that RETs act as a conduit between the distance schooling teacher and student, and that their role requires complex capabilities to be performed within a structured framework. Time restrictions with competing demands present a constant challenge to the RETs' work satisfaction. Constraining this occupation is the reality that there is no formal qualification available for RETs. Without specific credentialling, it appears that the RETs' (in)visible role risks being overlooked as a substantive educational occupation.

A national scheme for public access defibrillation in England and Wales: early results.

BACKGROUND: Automated external defibrillators (AEDs) operated by lay persons are used in the UK in a National Defibrillator Programme promoting public access defibrillation (PAD). METHODS: Two strategies are used: (1) Static AEDs installed permanently in busy public places operated by those working nearby. (2) Mobile AEDs operated by community first responders (CFRs) who travel to the casualty. RESULTS: One thousand five hundred and thirty resuscitation attempts. With static AEDs, return of spontaneous circulation (ROSC) was achieved in 170/437 (39%) patients, hospital discharge in 113/437 (26%). With mobile AEDs, ROSC was achieved in 110/1093 (10%), hospital discharge in 32 (2.9%) (P<0.001 for both variables). More shocks were administered with static AEDS 347/437 (79%) than mobile AEDs 388/1093 (35.5%) P<0.001. Highly significant advantages existed for witnessed arrests, administration of shocks, bystander CPR before arrival of AED and short delays to start CPR and attach AED. These factors were more common with static AEDs. For CFRs, patients at home did less well than those at other locations for ROSC (P<0.001) and survival (P=.006). Patients at home were older, more arrests were unwitnessed, fewer shocks were given, delays to start CPR and attach electrodes were longer. CONCLUSIONS: PAD is a highly effective strategy for patients with sudden cardiac arrest due to ventricular fibrillation who arrest in public places where AEDs are installed. Community responders who travel with an AED are less effective, but offer some prospect of resuscitation for many patients who would otherwise receive no treatment. Both strategies merit continuing development.

Site specific lymph node metastasis in carcinoma of the cervix: Is there a sentinel node?

Follow-up for at least 5 years was available for 350 cases of stage IB and IIA carcinoma of the cervix managed by radical hysterectomy and pelvic lymphadenectomy. Lymphadenectomy technique mapped the patterns of pelvic lymph node metastasis (LNM). The effects on survival of specific factors relating to the lymphadenectomy (node count, number of positive nodes, site of positive nodes, number of sites positive, location of highest positive node) were determined for 80 women with LNM. The location of metastatic disease did not significantly predict survival. The incidence of LNM was 23% and 47.5% of these women survived 5 years. Only 45% of cases with a solitary LNM survived 5 years and in 45% of these recurrence was outside the pelvis. With the exception of the presacral group, the finding of isolated LNM in any other group with metastasis to the left side of the pelvis conferred the worst prognosis. The pattern of LNM from early stage carcinoma of the cervix is therefore random and the concept of a sentinel node or group is not tenable.

Detection and measurement of DNA adducts in the cervix of smokers and non-smokers.

Smoking has been associated, on epidemiologic grounds, with an increased risk of cervical neoplasia. We have investigated this association, using laboratory-based methods. A 32P post-labeling assay was performed on 97 cervical biopsies to detect and measure DNA adducts (additional products formed by the covalent binding of potential chemical carcinogens to nuclear DNA). The specimens were taken from both normal cervices as well as the histologically normal regions of cervices with invasive and intraepithelial neoplasia. A detailed smoking history was obtained from each patient and correlated with an assay of cotinine level in urine. Characteristic smoking-related DNA adducts were found, and a significant difference in their levels was detected between current and non-current smokers (P = 0.017, Mann-Whitney test). There was also a highly significant trend in median adduct levels between the three tissue types (P < 0.002). We conclude that the finding of smoking-related cervical DNA damage is suggestive of a causal association between smoking and cervical neoplasia.

Intra-operative diagnosis of lymph node metastases in gynaecological practice using imprint cytology.

The technique of imprint cytology has been described for the assessment of malignancy and correlates well with histology. Despite the simplicity, speed and excellent cellular detail the technique has still not been fully appreciated. We describe the value of the technique applied to intra-operative diagnosis of lymph node metastases in gynaecological malignancy. Four hundred and seventy five lymph nodes were examined using imprint cytology followed by routine histology. The technique of imprint cytology was found to have a zero false negative rate, 0.6% false positive rate and an accuracy of 99.3%. We advocate the consideration of this technique for the evaluation of cases with gynaecological malignancy as an alternative to frozen section histology.

Adenocarcinoma of the cervix: a regional retrospective study.

A retrospective study using data from the Yorkshire Cancer Registry was undertaken to investigate the incidence, characteristics and prognosis of cases of cervical adenocarcinoma in the Yorkshire Region. Three hundred and twenty-six women resident in the Yorkshire Region formed the basis of the study. The overall five year survival for adenocarcinoma of the cervix is 53%. This was influenced by stage, lymph node involvement and differentiation. 37 out of 122 surgically treated patients received inappropriate treatment. There is a need for improved data collection in the treatment of these patients. This lends weight to the argument that cancer of the cervix should be managed in cancer units.

Letters.

SYSTEMIC HYPERBARIC OXYGEN THERAPY HYPOCHLORITE SOLUTIONS.

Lymphocele.

Lymphocele is a complication which will be familiar to the gynaecological surgeon, particularly the oncologist. It is also well recognised in association with urological pelvic surgery and renal transplantation. Occurrence of lymphocele has been described in relation to surgery in a wide variety of other areas including the mediastinum, axilla, neck, aorta and peripheral vasculature. Clearly many of these examples are unusual occurrences, but they serve to illustrate that this complication will be encountered occasionally by surgeons in any of a number of disciplines.

Learning to value differences. A Catholic healthcare system implements a cultural diversity education program.

Each year the U.S. labor force is becoming increasingly diverse. Many healthcare organizations are adopting plans to meet the needs of leaders who manage culturally diverse groups of employees and to ensure that the organization can continue to attract and retain employees of all cultures. In December 1988 Mercy Health Services, Farmington Hills, MI, began a cultural diversity program to increase the number of minority and women employees, especially in management and leadership positions. Its education program was designed to enhance manager and employee awareness of their own biases and those of others and to build skills in dealing with persons from a variety of cultures. Mercy Health Services first held 90-minute educational sessions for managers. The sessions covered expected demographic changes and the importance of working together. Employees then attended sessions where they practiced interactive exercises to help each person recognize his or her own biases. In the subsequent weeks the corporate human resources staff experienced an increase in the number of employee relations problems managers and nonmanagers attributed to diversity conflict. In response, Mercy developed a pilot series of awareness- and skill-building workshops for those who managed Mercy's most culturally diverse staffs. They heard lectures on racial and gender issues and watched and discussed conflict resolution videos. Most workshop participants increased their awareness of cultural bias and their commitment to learning and practicing skills to deal with conflict.

Amniocentesis with and without ultrasound guidance.

The increasing use of amniocentesis requires that the technique be made as safe as possible. The results of 284 amniocenteses done under ultrasound control are presented and compared with the results of 140 amniocenteses performed without ultrasound control. The use of ultrasound guidance increased the success rate from 80 to 99.6 per cent and decreased the incidence of feto-maternal haemorrhage from 8.5 to 2.8 per cent. The incidence of blood-stained amniotic fluid was reduced from 43.5 to 17.6 per cent. The clinical significance of these findings is discussed and the results interpreted as indicating that amniocentesis done with ultrasound guidance is a safer and less traumatic procedure.

Cervical smear histories of 500 women with invasive cervical cancer in Yorkshire.

The smear histories of 312 women with cancer of the cervix have been determined. Eighty nine women had had at least one negative smear reported in the 10 years before a diagnosis of cancer and 14 had had more than one negative smear. Fifty six of the 89 women had had a negative smear in the three years preceding the diagnosis of cancer. The highest number of negative smears (61) reported was among the 115 women aged under 45. Fifty eight slides reported as negative were submitted to independent review; 13 were subsequently reported as negative, 11 as unsatisfactory, and 34 as abnormal. These findings may in part explain why in this region there has been a disappointing reduction in the incidence of clinically invasive cervix cancer, and our findings may also apply elsewhere. Nevertheless, the confirmed negative smears chiefly occurred within three years of clinical cancer, particularly in the younger women, and this finding suggests that these women may have a short preinvasive phase.

The value of pre-operative intracavitary radiotherapy in patients treated by radical hysterectomy and pelvic lymphadenectomy for invasive carcinoma of the cervix.

Two hundred and twenty-four patients with invasive carcinoma of the cervix treated by radical surgery have been studied retrospectively to determine the impact of pre-operative intracavitary radiotherapy. Pre-operative radiotherapy made no difference to survival, the incidence of local recurrence, distant metastasis or complications.

Postoperative deep vein thrombosis: identifying high-risk patients.

A prospective study was carried out to confirm the validity of a predictive index for patients at risk of developing deep vein thrombosis. The index, which correctly identified nine out of 10 patients and incorrectly identified seven out of 52 patients as being at risk, is based on five variable--namely, the euglobulin lysis time, serum concentration of fibrin-related antigen, age, percentage overweight for height, and presence of varicose veins. Thus a population of patients at particularly high risk of developing postoperative deep vein thrombosis may be identified preoperatively by means of this index, so that prophylaxis may be used more rationally.

Prophylaxis of postoperative deep vein thrombosis: selective use of low-dose heparin in high-risk patients.

Administration of prophylactic low-dose subcutaneous heparin to prevent postoperative deep vein thrombosis is expensive, entails treating many patients unnecessarily, and causes some side effects. By using a predictive index a population of patients who are at particularly high risk of developing postoperative deep vein thrombosis may be identified preoperatively. Prophylaxis was given only to these patients, resulting in an incidence of deep vein thrombosis of 3.8% compared with 16.1% in previous studies in which no specific prophylaxis was given. By limiting prophylaxis to the group of patients identified by the predictive index as being at high risk of developing postoperative deep vein thrombosis results may be obtained that are as good as those expected from treating the whole population. Thus many patients are saved from exposure to low-dose subcutaneous heparin.

A prospective trial of computed tomography in the staging of ovarian malignancy.

Thirty patients, thought clinically to have ovarian tumours, were studied prospectively by pre-operative computed tomographic (CT) scans of the abdomen and pelvis. In six patients (20%) small metastases in mesentery, omentum and on subdiaphragmatic peritoneum were not detected by the scans. CT did not improve the accuracy of staging or assist the surgeons by drawing their attention to disease which they might otherwise have missed. Although CT gives an elegant demonstration of anatomy, it is not an alternative to extended laparotomy in patients with ovarian tumours.

Decision analysis for best management of mildly dyskaryotic smear.

Should a woman with a mildly dyskaryotic cervical smear be referred for colposcopy or should the smear be repeated? One way to answer this question is to use decision analysis and compare the expected mortality and cost of each policy. Data for each component of the question were obtained from published work worldwide and were supplemented with an audit of mildly dyskaryotic smears in West Yorkshire, UK. 2 out of 1000 women with an initial mildly dyskaryotic smear will develop cancer if a conservative repeat smear policy is adopted in association with five-yearly cervical screening. This number can be reduced to 1.6 per 1000 if cervical screening is offered every three years. A policy of immediate referral for colposcopy is also associated with a subsequent cancer rate of 1.6 per 1000. Therefore, repeating the smear is almost as effective as an immediate referral to a colposcopy unit. Even if a five-yearly cervical screening programme is adopted, 2500 women with a mildly dyskaryotic smear will need to be referred for immediate colposcopy to save 1 additional cancer. A conservative policy is not financially cheaper: an average of six additional smears is required to save each colposcopy referral. Sensitivity analysis shows that the excess cost of the conservative policy increases exponentially as the risk of a subsequent cytological abnormality exceeds 60%. Local cytopathology laboratories should audit their recurrent dyskaryosis rate associated with borderline, mild, and moderate dyskaryosis before accepting the U-turn in the national recommendations.

Which cervical sampler? A comparison of four methods.

Four cytology sampling methods were compared in 1063 patients referred for colposcopy with a recent abnormal smear. A dyskaryotic smear of any grade was considered a positive result, though comparisons were limited to cases with a subsequent biopsy confirming CINII or III. There were no differences between the abilities of any of the four methods to detect higher grades of CIN (chi (2)3 = 4.603, P > 0.20). The presence or absence of endocervical cells in a smear was not significantly associated with any variation in success rate (chi (2)1 = 0.959, P > 0.30). The joint analysis of the four methods and the presence/absence of endocervical cells also showed no significant effects (chi (2)7 = 12.768, 0.1 > P > 0.05). In the latter analysis the trend towards a conventional level of significance was accounted for by the Aylesbury spatula giving a relatively high success rate when endocervical cells were present. The suggestion of advantage for the Aylesbury spatula merits further investigation.

Cancer of the cervix in women under 40 years of age, a regional survey, 1975-1984.

OBJECTIVE: To review the method and results of treatment of carcinoma of the cervix in women less than 40 years old. DESIGN: Retrospective review of all available case records. SETTING: Yorkshire Regional Health Authority. SUBJECTS: 428 women less than 40 years old treated for stage IB-IV carcinoma of the cervix between 1975 and 1984 inclusive. MAIN OUTCOME MEASURES: Overall survival by stage, effect of age, identifiable factors of prognostic significance, survival, grade 3 morbidity and pattern of recurrence in relation to treatment. RESULTS: The 5-year actuarial percentage survival by stage was 78.4 (IB), 54.4 (II), 18.4 (III) and 0 (IV). Identifiable factors of prognostic importance were stage, nodal metastases (P less than 0.001) and tumour grade (P less than 0.01). CONCLUSION: Primary surgical treatment for young women with early disease allows ovarian conservation and the avoidance of radiotherapy in 80% of them. Such treatment results in less local recurrence, particularly evident in patients with moderate or poorly differentiated tumours and a lower incidence of serious morbidity.

Extraction of DNA from exfoliative cytology specimens and its suitability for analysis by the polymerase chain reaction.

The extraction of DNA from archival exfoliative cytology samples would allow the molecular biological analysis of this readily available material using the polymerase chain reaction (PCR). We have quantitatively and qualitatively studied the extraction of DNA from a variety of cytological preparations. For both fresh and archival cervical smears, overnight incubation with proteinase K produces high yields of high molecular weight DNA, but simply boiling the samples produces DNA suitable for PCR amplification of a single copy gene. Increasing the proteinase K incubation to several days allows the extraction of DNA from fixed and stained archival cytology slides from a variety of sites. The extracted DNA was again suitable for PCR analysis. Fresh and archival cytological material can be utilized for molecular biological study of disease processes using PCR. Archival cytological material is probably the best source of DNA and RNA after stored frozen tissue.